Long-term outcome of Heller myotomy in achalasic sigmoid esophagus

Objective: We sought to assess the long-term outcome of Heller myotomy and anterior fundoplication in patients with achalasic sigmoid esophagus. Methods: Fourteen patients with achalasia and sigmoid esophagus (median age, 42.5 years) operated on by the same surgeon through a laparotomy (n = 8) or laparoscopic approach (n = 6) between 1985 and 2000 were evaluated. According to a 4-grade classification (1, no symptoms; 4, persistent symptoms), both dysphagia and regurgitation bad a median score of 4.0. Five patients complained of respiratory symptoms. Six patients had undergone previous pneumatic dilation. Preoperative and postoperative workup included an esophagogram, esophagoscopy, manometry, and health-related quality-of-life assessment with the Short-Form 36-item questionnaire. Results: Median follow-up was 85 months. At 24 months, esophageal width decreased by 10 mm (P = .003), and the change correlated inversely with the age of the patients (R = -0.61; P = .02). Lower esophageal sphincter pressure decreased by 17 mm Hg (P = .001), and both dysphagia and regurgitation scores decreased to 1.0 (P < .003). Comparison with the results of 37 patients with earlier-stage achalasia showed no difference in changes of esophageal width, lower esophageal sphincter pressure, dysphagia score, and regurgitation score. Quality-of-life Short-Form 36-item questionnaire domains, including general health, social functioning, and vitality, improved significantly. Overall results were classified as excellent or good in 10 patients and as satisfactory and unsatisfactory in 2 patients each. No patient required esophagectomy or had esophageal carcinoma. Conclusion: In this study Heller myotomy proved effective in improving subjective, objective, and quality-of-life outcome measures in patients with achalasic sigmoid esophagus and should be considered as the first-choice treatment for this severe condition

The role of awake video-assisted thoracoscopic surgery in spontaneous pneumothorax

Objective: We assessed in a randomized study the feasibility and efficacy of awake video-assisted thoracoscopic bullectomy with pleural abrasion to treat spontaneous pneumothorax. Methods: Between January 2001 and June 2005, a total of 43 patients with primary spontaneous pneumothorax were randomly assigned by computer to undergo video-assisted thoracoscopic bullectomy and pleural abrasion under sole thoracic epidural anesthesia or general anesthesia with single-lung ventilation ( control group). Primary outcome measures included technical feasibility and patient satisfaction with anesthesia as scored into 4 grades ( from 1, unsatisfactory, to 4, excellent). Secondary outcome measures included global operating room time, assessment of thoracic pain by visual analog pain scale, number of nursing care calls, hospital stay, and recurrences within 12 months. Results: In the awake group, technical feasibility was scored as excellent, good, and satisfactory in 8, 7, and 6 patients, respectively. Intergroup comparisons ( awake versus control) showed that global operating room time ( 78.0 +/- 20.0 vs 105.0 +/- 15.0 minutes, P < .0001), perioperative visual analog pain scale score ( 2.0 +/- 3.0 vs 3.5 +/- 2.0, P = .005), nursing care calls ( 2.0 +/- 1 vs 3.0 +/- 3.0, P = .017), hospital stay ( 2.0 +/- 1.0 days vs 3.0 +/- 1.0 days, P < .0001), and overall costs ( euro2540 +/- euro352 vs euro3550 +/- euro435, P < .0001) were significantly better in the awake group. In the awake group, 5 patients ( 23.8%) could be discharged within the first 24 postoperative hours. One patient in the awake group and 2 patients in the control group had recurrences within 12 months ( difference not significant). Conclusion: In our study, awake video-assisted thoracoscopic bullectomy with pleural abrasion proved easily feasible and resulted in shorter hospital stays and reduced procedure-related costs while providing equivalent outcome to procedures performed under general anesthesia

Long-term results of tailored lung volume reduction surgery for severe emphysema

Objective. We analyzed the overall results with our lung volume reduction surgery (LVRS) program, which entailed unilateral and bilateral LVRS, selectively performed on the basis of precise clinical and radiologic morphology criteria. Materials and Methods. Between 1995 and 2005, 182 patients were operated on unilaterally (104 patients) or bilaterally (78 patients). Amongst bilateral procedures, 39 patients were operated in one-stage fashion and 39 in a staged fashion. Results. Overall 90-day mortality was 2.8% (4 patients). Mean follow-up was 51±30 months. Six months absolute improvement in forced expiratory volume in one second (FEV1) was 0.27±0.2L in the unilateral group, 0.38±0.2L in the staged bilateral group, and 0.45±0.2L in the one-stage group. Residual volume decrease were 1.1±0.5L, 0.99±0.3L, and 1.75±0.5L in the unilateral, staged bilateral and one stage bilateral groups, respectively. Overall, improvements in FEV1 occurred for up to 36 months in the unilateral group and for up to 48 months in the bilateral group. Residual volume remained improved for up to 72 months in the unilateral and staged bilateral groups, and for up to 48 months in the one-stage group. The SF-36 health-related quality of life physical functioning domain score remained improved for more than 48 months in all groups and for up to 72 months in the staged group only. Five-year survival were 78%, 88% and 77%, in the unilateral, staged bilateral and one-stage bilateral groups, respectively. Conclusions. We conclude that highly satisfactory long-term survival and long lasting clinical improvements occurred in patients undergoing unilateral or bilateral LVRS

Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules

Background. General anesthesia with single-lung ventilation is considered mandatory for thoracoscopic pulmonary resection. We assessed in a randomized study the feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. Methods. Between March 2001 and February 2003, 60 patients were randomized into two 30-patients arms: a general anesthesia arm entailing double-lumen intubation and thoracic epidural anesthesia (control group); and an awake arm entailing sole thoracic epidural anesthesia at T4-T5 (awake group). Anesthesia time; operative time; global operating room time; patient satisfaction with the anesthesia and technical feasibility scored into 4 grades (from 1 = poor to 4 = excellent); visual analog pain score (VAS), nursing care (number of patient calls per day), 24 hours changes in arterial oxygenation (DeltaNO(2)), and hospital stay were assessed. Results. There was no mortality. There was no difference in technical feasibility between the groups although 2 patients in the awake group required conversion to thoracotomy due to severe adhesions. Other 2 patients in each group required conversion due to unexpected lung cancer requiring lobectomy. Comparisons of awake versus control group results showed that in the awake group, anesthesia satisfaction score was greater (4 vs 3, p = 0.04), whereas DeltaPaO(2) (-3 mm Hg vs -6.5 mm Hg, p = 0.002); nursing care (2.5 calls per day vs 4 calls per day, p = 0.0001), and hospital stay (2 days vs 3 days, p = 0.02) were significantly reduced. Conclusions. In our study, awake thoracoscopic resection of solitary pulmonary nodules proved safely feasible. It resulted in better patient satisfaction, less nursing care and shorter in-hospital stay than procedures performed under general anesthesia. (C) 2004 by The Society of Thoracic Surgeons

Completion lobectomy after bilateral lung volume reduction for emphysema: Salvage option or fancy?

[No abstract available

Body weight and nutritional changes after reduction pneumoplasty for severe emphysema: A randomized study

Background: The impact of reduction pneumoplasty on body weight and nutritional status has not previously been tested in a controlled study. Methods: We investigated 60 patients with severe emphysema who were randomly assigned to receive either reduction pneumoplasty (n = 30) or a 6-week respiratory rehabilitation program (n = 30). Nutritional status was evaluated by means of body mass index, triceps skin fold measurement, midarm muscle circumference, and biochemical blood values. Fat mass and fat-free mass were calculated by bioelectric impedance. Two treatment-related deaths occurred after reduction pneumoplasty and 1 death occurred after respiratory rehabilitation. Results: Functional and subjective improvements were significantly showed in reduction pneumoplasty group. Despite insignificant differences in energy intake, the reduction pneumoplasty group showed significant gain (P < .0001) relative to the respiratory rehabilitation group in mean weight changes at 3 months (1.82 ± 2.63 kg vs -0.57 ± 2.25 kg), 6 months (2.87 ± 3.79 kg vs -1.11 ± 2.64 kg), and 12 months (3.29 ± 4.01 kg vs -0.95 ± 1.90 kg). Both fat mass and fat-free mass increased after surgery, but only fat-free mass had a significant improvement (P = .001). Six-month weight gain in the reduction pneumoplasty group was significantly correlated with low baseline weight (p = -0.437, P = .02) and residual volume reduction (p = -0.446, P = .01). Total proteins (P = .003), albumin (P = .03), transferrin (P = .04), cholesterol (P = .003), hemoglobin (P = .01), triceps skin fold measurement (P < .0001), and midarm muscle circumference (P < .0001) were significantly increased only in the reduction pneumoplasty group. Conversely, in the respiratory rehabilitation group no nutritional index was significantly increased at 6 months after rehabilitation. Conclusions: Body weight and nutritional status improved only after reduction pneumoplasty and not after respiratory rehabilitation, and this was significantly related to fat-free mass increment. In the reduction pneumoplasty group, the residual volume result was significantly correlated with postoperative weight gain

Extra-anatomic bypass of the superior vena cava after successful stenting for fibrosing mediastinitis

[No abstract available